Inter-examiner variances of pocket depth probing between periodontists and referring specialists

Transcription

1 RESEARCH REPORT 123 Publication Onur Ozcelik, M Cenk Haytac, Gulsah Seydaoglu Inter-examiner variances of pocket depth probing between periodontists and referring specialists KEY WORDS endodontic-periodontal lesions, inter-examiner differentiation, periodontal pocket depth, probing Aim: Pocket depth measurements are the main criteria diagnosing and assessing periodontal disease progression and the referral of patients to a periodontist. The aim of this study was to assess the inter-examiner variances of pocket depth measurements between two periodontists, an orthodontist, an oral surgeon and an endodontist. Study design: A total of 316 sites in 15 patients with aggressive periodontitis were measured two periodontists, one orthodontist, one oral surgeon and one endodontist. Inter-examiner variations were analysed the Spearman correlation test, Wilcoxon signed rank test, intra-class correlation and limits of agreement. Results: The results of this study show that the pocket depth measurements of dentists from other specialties were always lower compared with the periodontists (p < ). The inter-examiner reliability analysis revealed that the oral surgeon had acceptable excellent correlation compared with the periodontists, while the endodontist and the orthodontist had acceptable moderate correlation. The limits of agreement analysis showed that 40%, 30% and 20% of the measurements of the surgeon, endodontist and orthodontist respectively were the same as those of the periodontists. Conclusions: The results of this study emphasise the importance of the development of a probe design, either automated or manual, with constant ce, and a guidance system to ensure proper angulations. Only then will the dentists be able to perm accurate probing to diagnose and differentiate certain situations, which will subsequently help them to perm appropriate treatment or to refer on time. Onur Ozcelik Faculty of Dentistry, Department of Periodontology, Balcali 01330, Tel: Fax: oozcelik@cu.edu.tr M Cenk Haytac Faculty of Dentistry, Department of Periodontology, Gulsah Seydaoglu Faculty of Medicine, Department of Biostatistics, Introduction Pocket depth and attachment level measurements are still the most important and most frequently used diagnostic tools to determine the presence, progression and severity of destructive periodontal diseases 1,2. These measurements are assessed manual and automated periodontal probes, and many studies have been conducted to assess the reliability of these probes 3 9. The intra- and inter-examiner consistencies of the data of these probes are still to be determined and it has been reported that

2 124 Ozcelik et al Probing depth variations between specialists the standard deviation of conventional probes is ± 0.82 mm The reliability of probing measurements depends mainly on the location of the pocket, the angulation and physical properties of the probe, the disease status and on the clinician perming the measurements 9, The current gold standard assessing periodontal disease progression or response to treatment in clinical studies also involves the probing of pocket depth and attachment level either the same examiner in repeated measurements or different examiners, particularly in longitudinal studies 10, Besides periodontology, these measurements are also used in other fields of dental science such as oral surgery 18-20, orthodontics and endodontics 25,26. While significant intra- and inter-examiner variations of probing pocket depth have been reported even among experienced periodontists who use the probes most frequently, to our knowledge there are no studies that compare the probing depth measurements of dentists belonging to various specialties. Theree, the aim of this study was to assess the inter-examiner variances of probing measurements between two periodontists, an orthodontist, an oral surgeon and an endodontist. Study design The study protocol was approved the institutional review board, and all patients involved in the study provided written inmed consent. Two periodontists, an orthodontist, an oral surgeon and an endodontist, each with at least 5 years of experience, agreed to participate in the study. They were all re-trained another experienced periodontist in the theoretical and clinical aspects of periodontal probing. Each specialist was asked to undertake probing of 100 sites ten patients in order to verify if their intra-examiner calibration readings reached an acceptable standard. All patients were examined twice with at least a 10-minute break between examinations. The intra-examiner calibration results were accepted if the repeated measurements were similar at a 90% level. Finally, each of these five examiners measured probing depths of 15 patients with aggressive periodontitis who had pocket depths ranging from 1 mm Publication to 12 mm. A UNC-15 manual probe was used in this study. All the teeth present were recorded, except third molars, and the measurements were taken from four sites of each tooth: mesio-buccal, disto-buccal, mid-vestibular and mid-lingual. All measurements were carried out under standard conditions in terms of ergonomic positions, and the sequence of examiner probing was rotated. As it has been reported that repeated probing of the same site in less than 5 minutes could induce changes within the pocket that can influence subsequent measurements, at least 10 minutes were allowed to elapse between each examiner. The dentists were blinded to each other s measurements. Each examiner probed a total of 316 sites. Statistics The probing depth measurements of the two periodontists were pooled and averaged, and the obtained data were included as single measurements in the statistical analysis. Probing depth was considered as a continuous variable and Spearman correlation test was used to analyse the inter-examiner agreement between two periodontists and other dentists. In addition, inter-examiner variation each region between periodontists and other dentists was calculated the Wilcoxon signed rank test. Inter-examiner agreement was assessed using intra-class correlation (ICC) and limits of agreement (LOA) a computer program (SPSS v.12.0). ICC was expressed according to Goulet and Clark 27 as: 'unacceptable' (values between 0.00 and 0.39); 'moderate' (values between 0.40 and 0.59); 'acceptable' (values between 0.60 and 0.79); 'excellent' (values between 0.80 and 1.00). Results The results showed high correlation between two periodontists (r = 0.92). Table 1 shows that the probing depth measurements of the dentists from other specialties were statistically lower compared with the periodontists (p < ), in both the anterior and posterior regions. The correlation and the interexaminer reliability analysis of other dentists compared with the periodontists, determined Spear-

3 Ozcelik et al Probing depth variations between specialists 125 Publication Table 1 Mean pocket depth measurements (mm, mean ± SEM) according to the examiner and region. Results in parentheses are mean difference from the periodontists. Anterior (n = 162) 4.42 ± 0.16 Posterior (n = 154) 4.25 ± 0.12 Total (n = 316) 4.34 ± 0.10 Periodontists Surgeon Endodontist Orthodontist 4.01 ± 0.15* ( 0.40) 3.44 ± 0.10* ( 0.81) 3.73 ± 0.09* ( 0.60) 3.46 ± 0.12* ( 0.96) 3.07 ± 0.08* ( 1.18) 3.27 ± 0.08* ( 1.06) 3.00 ± 0.11* ( 1.41) 2.86 ± 0.07* ( 1.39) 2.93 ± 0.07* (-1.40) p < surgeon, endodontist and orthodontist versus periodontists anterior, posterior and total. Table 2 Inter-examiner correlation with Spearman test and reliability with intra-class (ICC) statistics. Periodontists Anterior (n = 162) Posterior (n = 154) Total (n = 316) Surgeon* ( ) Excellent ( ) ( ) Excellent Endodontist* ( ) ( ) Moderate ( ) Orthodontist* ( ) ( ) Moderate ( ) * p < 0.01 Table 3 Limits of agreement of the specialists with the periodontists. Anterior Posterior Total n % n % n % Surgeon Endodontist Orthodontist man test and ICC statistics respectively, showed that the oral surgeon had acceptable excellent correlation while the endodontist and the orthodontist had acceptable moderate correlation (Table 2). The LOA analysis showed that while 40% of the measurements of the surgeon were the same as those of the periodontists, this value was only 30% and 20% of the measurements of the endodontist and orthodontist respectively (Table 3). Of the measurements of the orthodontist, 42.4% had a variation of ± 2 mm or more compared with the periodontists.

4 126 Ozcelik et al Probing depth variations between specialists Discussion The aim of this study was to assess the probing depth differences between dentists belonging to various specialties. The results of this study cannot be generalised all specialists, since probing is highly individualistic and can be affected various personal factors such as the experience of the clinician, the expertise of dealing with gingival tissues, and the familiarity or frequency of the use of periodontal probes. However, since probing depth measurements still remain the gold standard the diagnosis of periodontal diseases and constitute the main criteria the referral of patients to a periodontist, our main purpose was to determine whether dentists from various specialties could adequately evaluate pocket depths after education and training. Overall, the results of this study have shown that the pocket depth measurements of dentists from other specialties were always lower compared with the periodontists, on both the anterior and posterior teeth. Correlation to the periodontist was highest with the oral surgeon, followed the endodontist. The orthodontist had the least correlation with the periodontists. It may be conjectured that the surgeons who deal with oral soft tissues more often than the other two specialists may be more capable of probing pockets. Orthodontic and endodontic therapy is usually permed on dental hard tissues only, which may result in these specialists being less familiar with working on gingival tissues. It should be noted that the clinical attachment level measurement from the cemento-enamel junction or another fixed point, which is considered to be more difficult than pocket depth measurement, was not assessed in this study. It may be assumed that the intra-examiner differences would be more important in that case. The main importance of probing depth measurements is the diagnosis of periodontal diseases. Other dental specialists may also be able to accurately diagnose periodontal diseases without accurate probing, especially in advanced cases. However, when the disease is limited to several teeth or a certain site of a tooth, the need acceptable probing is obvious. Furthermore, the differential diagnoses of certain conditions also rely on accurate probing. For example, the main criteria establishing the difference Publication of a periodontal abscess from an endodontic abscess requires the detection of a deep periodontal pocket extending into the abscess 25. In the field of oral surgery, it is very important to recognise the pocket depths of peri-implant tissues, in order to recognise an early inflammation 28. In addition, determining the long-term prognosis of re-implanted traumatised teeth also relies on precise probing 20. Accurate probing is also important orthodontists, who usually treat patients in puberty and adolescence 16, Certain ms of destructive periodontal diseases, such as aggressive periodontitis, are usually diagnosed during these periods, and orthodontists may be the first to recognise and refer the patients with these conditions to a periodontist. Finally, pocket depths must be detected correctly orthodontists when planning appropriate orthodontic treatment in adult patients, especially those who had previous destructive periodontal diseases 22. The results of this study emphasise the importance of the development of a probe design, either automated or manual, with constant ce, and a guidance system to ensure proper angulations. Only then will the examiner related variables such as experience and familiarity with periodontal probes be rendered less important and allow clinicians to adequately diagnose periodontal diseases. Acknowledgements The authors thank Dr Roland Blankenstein and Osman Ozcan their valuable assistance. References 1. Listgarten MA. Periodontal probing: what does it mean? J Clin Periodontol 1980;13: Caton, J, Greenstein G, Polson A. Depth of periodontal probe penetration related to clinical and histologic signs of inflammation. J Periodontol 1981;52: Gibbs CH, Hisrchfeld JW, Lee JG. Description and clinical evaluation of a new computerized periodontal probe the Florida Probe. J Clin Periodontol 1988;15: Mullally BH, Linden GJ. Comparative reproducibility of proximal probing depth using electronic pressure-controlled and hand probing. J Clin Periodontol 1994;21: Araujo MW, Hovey KM, Benedek JR, Grossi SG, Dorn J, Wactawski-Wende J et al. Reproducibility of probing depth measurement using a constant-ce electronic probe: analysis of inter- and intraexaminer variability. J Periodontol 2003;74: Khocht A, Chang KM. Clinical evaluation of electronic and manual constant ce probes. J Periodontol 1998;69:19 25.

5 Ozcelik et al Probing depth variations between specialists Karpinia K, Magnusson I, Gibbs C, Yang MCK. Accuracy of probing attachment levels using a CEJ Probe versus traditional probes. J Clin Periodontol 2004;31: Mayfield L, Bratthall G, Attstrom R. Periodontal probe precision using 4 different periodontal probes. J Clin Periodontol 1996;23: Fleiss JL, Park MH, Chilton NW. Within-mouth correlations and reliabilities probing depth and attachment level. J Periodontol 1987;58: Badersten A, Nilveus R, Egelberg J. Reproducibility of probing attachment level measurements. J Clin Periodontol 1984;11: Buduneli E, Aksoy O, Kose T, Atilla G. Accuracy and reproducibility of two manual periodontal probes. An in vitro study. J Clin Periodontol 2004;31: Wang SF, Leknes KN, Zimmerman GJ, Sigurdsson TJ, Wikesjo UM, Selvig KA. Intra- and inter-examiner reproducibility in constant ce probing. J Clin Periodontol 1995;22: Walsh TF, Sax MS. Inter- and intra-examiner variability using standard and constant ce periodontal probes. J Clin Periodontol 1989;16: Moriarty JD, Scheitler LE, Hutchens LH Jr, Delong ER. Interexaminer reproducibility of probing pocket depths in molar furcation sites. J Clin Periodontol 1988;15: Fleiss JL, Mann J, Paik M, Goultchin J, Chilton NW. A study of inter- and intra-examiner reliability of pocket depth and attachment level. J Periodontal Res 1991;26: Zappa U, Simona C, Graf H, Case D, Thomas J. Reliability of single and double probing attachment level measurements. J Clin Periodontol 1995;22: Grossi SG, Dund RG, Ho A, Koch G, Machtei EE, Genco RJ. Sources of error periodontal probing measurements. J Periodontal Res 1996;31: Blakey GH, Jacks MT, Offenbacher S, Nance PE, Phillips C, Haug RH, White RP Jr. Progression of periodontal disease in the second/third molar region in subjects with asymptomatic third molars. J Oral Maxillofac Surg 2006;64: Krausz AA, Machtei EE, Peled M. Effects of lower third molar extraction on attachment level and alveolar bone height of the adjacent second molar. Int J Oral Maxillofac Surg 2005;34: Hamamoto Y, Takahashi K, Sakurai H. The use of enamel matrix derivative (Emdogain ) improvement of probing attachment level of the autotransplanted teeth. Dent Traumatol 2005;21: Huang CH, Brunsvold MA. Reactive correction of a maxillary incisor in single-tooth crossbite following periodontal therapy. J Periodontol 2005;76: Cardaropoli D, Re S, Corrente G, Abundo R. Reconstruction of the maxillary midline papilla following a combined orthodontic-periodontic treatment in adult periodontal patients. J Clin Periodontol 2004;31: Chaushu S, Brin I, Ben-Bassat Y, Zilberman Y, Becker A. Periodontal status following surgical-orthodontic alignment of impacted central incisors with an open-eruption technique. Eur J Orthod 2003;25: Artun J, Grobety D. Periodontal status of mandibular incisors after pronounced orthodontic advancement during adolescence: a follow-up evaluation. Am J Orthod Dentofacial Orthop 2001;119: Vakalis SV, Whitworth JM, Ellwood RP, Preshaw PM. A pilot study of treatment of periodontal-endodontic lesions. Int Dent J 2005;: Stassen IG, Hommez GM, De Bruyn H, De Moor RJ. The relation between apical periodontitis and root-filled teeth in patients with periodontal treatment need. Int End J 2006; 39: Goulet JP, Clark GT. Clinical TMJ examination methods. J Calif Dent Assoc 1990;18: Elkhoury JS, McGlumphy EA, Tatakis DN, Beck FM. Clinical parameters associated with success and failure of singletooth titanium plasma-sprayed cylindric implants under stricter criteria: a 5-year retrospective study. Int J Oral Maxillofac Implants 2005;20: Publication